<div class="grid_20           push_4" id="bodyContent">



         
<script type="text/javascript">&lt;!--
var form = "";
var submitted = false;
var error = false;
var error_message = "";

function check_input(field_name, field_size, message) {
  if (form.elements[field_name] &amp;&amp; (form.elements[field_name].type != "hidden")) {
    var field_value = form.elements[field_name].value;

    if (field_value.length &lt; field_size) {
      error_message = error_message + "* " + message + "\n";
      error = true;
    }
  }
}

function check_radio(field_name, message) {
  var isChecked = false;

  if (form.elements[field_name] &amp;&amp; (form.elements[field_name].type != "hidden")) {
    var radio = form.elements[field_name];

    for (var i=0; i&lt;radio.length; i++) {
      if (radio[i].checked == true) {
        isChecked = true;
        break;
      }
    }

    if (isChecked == false) {
      error_message = error_message + "* " + message + "\n";
      error = true;
    }
  }
}

function check_select(field_name, field_default, message) {
  if (form.elements[field_name] &amp;&amp; (form.elements[field_name].type != "hidden")) {
    var field_value = form.elements[field_name].value;

    if (field_value == field_default) {
      error_message = error_message + "* " + message + "\n";
      error = true;
    }
  }
}

function check_password(field_name_1, field_name_2, field_size, message_1, message_2) {
  if (form.elements[field_name_1] &amp;&amp; (form.elements[field_name_1].type != "hidden")) {
    var password = form.elements[field_name_1].value;
    var confirmation = form.elements[field_name_2].value;

    if (password.length &lt; field_size) {
      error_message = error_message + "* " + message_1 + "\n";
      error = true;
    } else if (password != confirmation) {
      error_message = error_message + "* " + message_2 + "\n";
      error = true;
    }
  }
}

function check_form(form_name) {
  if (submitted == true) {
    alert("This form has already been submitted. Please press Ok and wait for this process to be completed.");
    return false;
  }

  error = false;
  form = form_name;
  error_message = "Errors have occured during the process of your form.\n\nPlease make the following corrections:\n\n";

  check_radio("gender", "Please select your Gender.");

  check_input("firstname", 2, "Your First Name must contain a minimum of 2 characters.");
  check_input("lastname", 2, "Your Last Name must contain a minimum of 2 characters.");

  check_input("dob", 10, "Your Date of Birth must be in this format: MM/DD/YYYY (eg 05/21/1970)");

  check_input("email_address", 6, "Your E-Mail Address must contain a minimum of 6 characters.");
  check_input("street_address", 5, "Your Street Address must contain a minimum of 5 characters.");
  check_input("postcode", 4, "Your Post Code must contain a minimum of 4 characters.");
  check_input("city", 3, "Your City must contain a minimum of 3 characters.");

  check_input("state", 2, "Your State must contain a minimum of 2 characters.");

  check_select("country", "", "You must select a country from the Countries pull down menu.");

  check_input("telephone", 3, "Your Telephone Number must contain a minimum of 3 characters.");

  check_password("password", "confirmation", 5, "Your Password must contain a minimum of 5 characters.", "The Password Confirmation must match your Password.");
  check_password("password_new", "password_confirmation", 5, "Your new Password must contain a minimum of 5 characters.", "The Password Confirmation must match your new Password.");

  if (error == true) {
    alert(error_message);
    return false;
  } else {
    submitted = true;
    return true;
  }
}
//--&gt;</script>

<h1><cufon class="cufon cufon-canvas" alt="My " style="width: 40px; height: 32px;"><canvas width="54" height="29" style="width: 54px; height: 29px; top: 4px; left: 0px;"></canvas><cufontext>My </cufontext></cufon><cufon class="cufon cufon-canvas" alt="Account " style="width: 92px; height: 32px;"><canvas width="106" height="29" style="width: 106px; height: 29px; top: 4px; left: 0px;"></canvas><cufontext>Account </cufontext></cufon><cufon class="cufon cufon-canvas" alt="Information" style="width: 111px; height: 32px;"><canvas width="124" height="29" style="width: 124px; height: 29px; top: 4px; left: 0px;"></canvas><cufontext>Information</cufontext></cufon></h1>

<br>
<p><font color="#FF0000"><small><strong>NOTE:</strong></small></font> If you already have an account with us, please login at the <a href="/login.php"><u>login page</u></a>.</p>

<form onsubmit="return check_form(create_account);" method="post" action="/create_account.php" name="create_account"><input type="hidden" value="0cfb26986a35440900a2bae003c648e8" name="formid"><input type="hidden" value="process" name="action">
<div class="contentContainer">
  <div>
    <span style="float: right; margin-right:10px" class="inputRequirement">* Required information</span>
    <h2>Your Personal Details</h2>
  </div>

  <div class="contentText">
    <table width="100%" cellspacing="2" cellpadding="2" border="0">


      <tbody><tr>
        <td class="fieldKey">Gender:</td>
        <td class="fieldValue"><input type="radio" value="m" name="gender">&nbsp;&nbsp;Male&nbsp;&nbsp;<input type="radio" value="f" name="gender">&nbsp;&nbsp;Female&nbsp;<span class="inputRequirement">*</span></td>
      </tr>


      <tr>
        <td class="fieldKey">First Name:</td>
        <td class="fieldValue"><input type="text" name="firstname">&nbsp;<span class="inputRequirement">*</span></td>
      </tr>
      <tr> 
        <td class="fieldKey">Last Name:</td>
        <td class="fieldValue"><input type="text" name="lastname">&nbsp;<span class="inputRequirement">*</span></td>
      </tr>


      <tr>
        <td class="fieldKey">Date of Birth:</td>
        <td class="fieldValue"><input type="text" id="dob" name="dob" class="hasDatepicker">&nbsp;<span class="inputRequirement">* (eg. 05/21/1970)</span><script type="text/javascript">$('#dob').datepicker({dateFormat: 'mm/dd/yy', changeMonth: true, changeYear: true, yearRange: '-100:+0'});</script></td>
      </tr>


      <tr>
        <td class="fieldKey">E-Mail Address:</td>
        <td class="fieldValue"><input type="text" name="email_address">&nbsp;<span class="inputRequirement">*</span></td>
      </tr>
    </tbody></table>
  </div>


  <h2>Company Details</h2>

  <div class="contentText">
    <table width="100%" cellspacing="2" cellpadding="2" border="0">
      <tbody><tr>
        <td class="fieldKey">Company Name:</td>
        <td class="fieldValue"><input type="text" name="company">&nbsp;</td>
      </tr>
    </tbody></table>
  </div>


  <h2>Your Address</h2>

  <div class="contentText">
    <table width="100%" cellspacing="2" cellpadding="2" border="0">
      <tbody><tr>
        <td class="fieldKey">Street Address:</td>
        <td class="fieldValue"><input type="text" name="street_address">&nbsp;<span class="inputRequirement">*</span></td>
      </tr>


      <tr>
        <td class="fieldKey">Suburb:</td>
        <td class="fieldValue"><input type="text" name="suburb">&nbsp;</td>
      </tr>


      <tr>
        <td class="fieldKey">Post Code:</td>
        <td class="fieldValue"><input type="text" name="postcode">&nbsp;<span class="inputRequirement">*</span></td>
      </tr>
      <tr>
        <td class="fieldKey">City:</td>
        <td class="fieldValue"><input type="text" name="city">&nbsp;<span class="inputRequirement">*</span></td>
      </tr>


      <tr>
        <td class="fieldKey">State/Province:</td>
        <td class="fieldValue">
<input type="text" name="state">&nbsp;<span class="inputRequirement">*</span>        </td>
      </tr>


      <tr>
        <td class="fieldKey">Country:</td>
        <td class="fieldValue"><select name="country"><option selected="selected" value="">Please Select</option><option value="1">Afghanistan</option><option value="2">Albania</option><option value="3">Algeria</option><option value="4">American Samoa</option><option value="5">Andorra</option><option value="6">Angola</option><option value="7">Anguilla</option><option value="8">Antarctica</option><option value="9">Antigua and Barbuda</option><option value="10">Argentina</option><option value="11">Armenia</option><option value="12">Aruba</option><option value="13">Australia</option><option value="14">Austria</option><option value="15">Azerbaijan</option><option value="16">Bahamas</option><option value="17">Bahrain</option><option value="18">Bangladesh</option><option value="19">Barbados</option><option value="20">Belarus</option><option value="21">Belgium</option><option value="22">Belize</option><option value="23">Benin</option><option value="24">Bermuda</option><option value="25">Bhutan</option><option value="26">Bolivia</option><option value="27">Bosnia and Herzegowina</option><option value="28">Botswana</option><option value="29">Bouvet Island</option><option value="30">Brazil</option><option value="31">British Indian Ocean Territory</option><option value="32">Brunei Darussalam</option><option value="33">Bulgaria</option><option value="34">Burkina Faso</option><option value="35">Burundi</option><option value="36">Cambodia</option><option value="37">Cameroon</option><option value="38">Canada</option><option value="39">Cape Verde</option><option value="40">Cayman Islands</option><option value="41">Central African Republic</option><option value="42">Chad</option><option value="43">Chile</option><option value="44">China</option><option value="45">Christmas Island</option><option value="46">Cocos (Keeling) Islands</option><option value="47">Colombia</option><option value="48">Comoros</option><option value="49">Congo</option><option value="50">Cook Islands</option><option value="51">Costa Rica</option><option value="52">Cote D'Ivoire</option><option value="53">Croatia</option><option value="54">Cuba</option><option value="55">Cyprus</option><option value="56">Czech Republic</option><option value="57">Denmark</option><option value="58">Djibouti</option><option value="59">Dominica</option><option value="60">Dominican Republic</option><option value="61">East Timor</option><option value="62">Ecuador</option><option value="63">Egypt</option><option value="64">El Salvador</option><option value="65">Equatorial Guinea</option><option value="66">Eritrea</option><option value="67">Estonia</option><option value="68">Ethiopia</option><option value="69">Falkland Islands (Malvinas)</option><option value="70">Faroe Islands</option><option value="71">Fiji</option><option value="72">Finland</option><option value="73">France</option><option value="74">France, Metropolitan</option><option value="75">French Guiana</option><option value="76">French Polynesia</option><option value="77">French Southern Territories</option><option value="78">Gabon</option><option value="79">Gambia</option><option value="80">Georgia</option><option value="81">Germany</option><option value="82">Ghana</option><option value="83">Gibraltar</option><option value="84">Greece</option><option value="85">Greenland</option><option value="86">Grenada</option><option value="87">Guadeloupe</option><option value="88">Guam</option><option value="89">Guatemala</option><option value="90">Guinea</option><option value="91">Guinea-bissau</option><option value="92">Guyana</option><option value="93">Haiti</option><option value="94">Heard and Mc Donald Islands</option><option value="95">Honduras</option><option value="96">Hong Kong</option><option value="97">Hungary</option><option value="98">Iceland</option><option value="99">India</option><option value="100">Indonesia</option><option value="101">Iran (Islamic Republic of)</option><option value="102">Iraq</option><option value="103">Ireland</option><option value="104">Israel</option><option value="105">Italy</option><option value="106">Jamaica</option><option value="107">Japan</option><option value="108">Jordan</option><option value="109">Kazakhstan</option><option value="110">Kenya</option><option value="111">Kiribati</option><option value="112">Korea, Democratic People's Republic of</option><option value="113">Korea, Republic of</option><option value="114">Kuwait</option><option value="115">Kyrgyzstan</option><option value="116">Lao People's Democratic Republic</option><option value="117">Latvia</option><option value="118">Lebanon</option><option value="119">Lesotho</option><option value="120">Liberia</option><option value="121">Libyan Arab Jamahiriya</option><option value="122">Liechtenstein</option><option value="123">Lithuania</option><option value="124">Luxembourg</option><option value="125">Macau</option><option value="126">Macedonia, The Former Yugoslav Republic of</option><option value="127">Madagascar</option><option value="128">Malawi</option><option value="129">Malaysia</option><option value="130">Maldives</option><option value="131">Mali</option><option value="132">Malta</option><option value="133">Marshall Islands</option><option value="134">Martinique</option><option value="135">Mauritania</option><option value="136">Mauritius</option><option value="137">Mayotte</option><option value="138">Mexico</option><option value="139">Micronesia, Federated States of</option><option value="140">Moldova, Republic of</option><option value="141">Monaco</option><option value="142">Mongolia</option><option value="143">Montserrat</option><option value="144">Morocco</option><option value="145">Mozambique</option><option value="146">Myanmar</option><option value="147">Namibia</option><option value="148">Nauru</option><option value="149">Nepal</option><option value="150">Netherlands</option><option value="151">Netherlands Antilles</option><option value="152">New Caledonia</option><option value="153">New Zealand</option><option value="154">Nicaragua</option><option value="155">Niger</option><option value="156">Nigeria</option><option value="157">Niue</option><option value="158">Norfolk Island</option><option value="159">Northern Mariana Islands</option><option value="160">Norway</option><option value="161">Oman</option><option value="162">Pakistan</option><option value="163">Palau</option><option value="164">Panama</option><option value="165">Papua New Guinea</option><option value="166">Paraguay</option><option value="167">Peru</option><option value="168">Philippines</option><option value="169">Pitcairn</option><option value="170">Poland</option><option value="171">Portugal</option><option value="172">Puerto Rico</option><option value="173">Qatar</option><option value="174">Reunion</option><option value="175">Romania</option><option value="176">Russian Federation</option><option value="177">Rwanda</option><option value="178">Saint Kitts and Nevis</option><option value="179">Saint Lucia</option><option value="180">Saint Vincent and the Grenadines</option><option value="181">Samoa</option><option value="182">San Marino</option><option value="183">Sao Tome and Principe</option><option value="184">Saudi Arabia</option><option value="185">Senegal</option><option value="186">Seychelles</option><option value="187">Sierra Leone</option><option value="188">Singapore</option><option value="189">Slovakia (Slovak Republic)</option><option value="190">Slovenia</option><option value="191">Solomon Islands</option><option value="192">Somalia</option><option value="193">South Africa</option><option value="194">South Georgia and the South Sandwich Islands</option><option value="195">Spain</option><option value="196">Sri Lanka</option><option value="197">St. Helena</option><option value="198">St. Pierre and Miquelon</option><option value="199">Sudan</option><option value="200">Suriname</option><option value="201">Svalbard and Jan Mayen Islands</option><option value="202">Swaziland</option><option value="203">Sweden</option><option value="204">Switzerland</option><option value="205">Syrian Arab Republic</option><option value="206">Taiwan</option><option value="207">Tajikistan</option><option value="208">Tanzania, United Republic of</option><option value="209">Thailand</option><option value="210">Togo</option><option value="211">Tokelau</option><option value="212">Tonga</option><option value="213">Trinidad and Tobago</option><option value="214">Tunisia</option><option value="215">Turkey</option><option value="216">Turkmenistan</option><option value="217">Turks and Caicos Islands</option><option value="218">Tuvalu</option><option value="219">Uganda</option><option value="220">Ukraine</option><option value="221">United Arab Emirates</option><option value="222">United Kingdom</option><option value="223">United States</option><option value="224">United States Minor Outlying Islands</option><option value="225">Uruguay</option><option value="226">Uzbekistan</option><option value="227">Vanuatu</option><option value="228">Vatican City State (Holy See)</option><option value="229">Venezuela</option><option value="230">Viet Nam</option><option value="231">Virgin Islands (British)</option><option value="232">Virgin Islands (U.S.)</option><option value="233">Wallis and Futuna Islands</option><option value="234">Western Sahara</option><option value="235">Yemen</option><option value="236">Yugoslavia</option><option value="237">Zaire</option><option value="238">Zambia</option><option value="239">Zimbabwe</option></select>&nbsp;<span class="inputRequirement">*</span></td>
      </tr>
    </tbody></table>
  </div>

  <h2>Your Contact Information</h2>

  <div class="contentText">
    <table width="100%" cellspacing="2" cellpadding="2" border="0">
      <tbody><tr>
        <td class="fieldKey">Telephone Number:</td>
        <td class="fieldValue"><input type="text" name="telephone">&nbsp;<span class="inputRequirement">*</span></td>
      </tr>
      <tr>
        <td class="fieldKey">Fax Number:</td>
        <td class="fieldValue"><input type="text" name="fax">&nbsp;</td>
      </tr>
      <tr>
        <td class="fieldKey">Newsletter:</td>
        <td class="fieldValue"><input type="checkbox" value="1" name="newsletter">&nbsp;</td>
      </tr>
    </tbody></table>
  </div>

  <h2>Your Password</h2>

  <div class="contentText">
    <table width="100%" cellspacing="2" cellpadding="2" border="0">
      <tbody><tr>
        <td class="fieldKey">Password:</td>
        <td class="fieldValue"><input type="password" maxlength="40" name="password">&nbsp;<span class="inputRequirement">*</span></td>
      </tr>
      <tr>
        <td class="fieldKey">Password Confirmation:</td>
        <td class="fieldValue"><input type="password" maxlength="40" name="confirmation">&nbsp;<span class="inputRequirement">*</span></td>
      </tr>
    </tbody></table>
  </div>

  <div class="buttonSet">
    <span class="buttonAction"><span class=" "><button type="submit" id="tdb9" class="ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary ui-priority-primary" role="button" aria-disabled="false"><span class="ui-button-icon-primary ui-icon ui-icon-person"></span><span class="ui-button-text">Continue</span></button></span><script type="text/javascript">$("#tdb9").button({icons:{primary:"ui-icon-person"}}).addClass("ui-priority-primary").parent().removeClass("tdbLink");</script></span>
  </div>
  <div class="clear"></div><br>
</div>

</form>



			
</div>